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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600073
Report Date: 08/14/2020
Date Signed: 08/14/2020 07:19:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CASA SANDOVALFACILITY NUMBER:
015600073
ADMINISTRATOR:ROSANA FRIASFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:99CENSUS: 55DATE:
08/14/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Paul Gozon/Executive DirectorTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted a case management inspection relating to the pre-licensing inspection for license application for change in ownership.

Due to Shelter in Place Order and directive from management to telework, LPA conducted inspection via video conference with Paul Gozon/Executive Director. LPA inspected the facility including but not limited to multi purpose room, model units, activity rooms, ice cream parlor room, main lounge, common areas, kitchen, courtyards, dining rooms on first and second floors, kitchen. LPA observed adequate lighting and hallways and courtyards free of obstructions. Food supplies were sufficient good for seven (7) days of non-perishables and two (2) day of perishables. Food supplies are delivered twice a week. Refrigerator and walk-in freezer temperatures were checked which showed at 36 and -15 degrees Fahrenheit respectively. Fire extinguisher in the kitchen showed serviced on April 28 2020. There were evacuation chairs on all stairwells. Ten apartment units were randomly selected for inspection, five (5) on the second floor and five (5) on the third floor. Hot water temperature was tested in one of the apartments on the second floor and measured at 109.4 degrees Fahrenheit. One of the call button of the resident was tested and observed working.

LPA observed the following:
  • pepto bismol unlocked in resident's (R1) apartment's medicine cabinet. Physician's Report revealed R1 can not administrator own prescription and PRN medications.
  • carpet flooring in resident's (R2) apartment.


..........continued on 809C
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CASA SANDOVAL
FACILITY NUMBER: 015600073
VISIT DATE: 08/14/2020
NARRATIVE
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Deficiencies are cited from Title 22 California Code of Regulations (see 809Ds). Failure to submit proof of corrections by plan of correction due dates and any repeat violations within twelve month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Mr. Gozon.

Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided via e-mail.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CASA SANDOVAL
FACILITY NUMBER: 015600073
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2020
Section Cited

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87465 Incidental Medical and Dental Care: (h) (1) Medications shall be centrally stored under the following circumstances:
(B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed.
This requirement is not met as evidenced by:
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-Based on obervation and document review, the licensee did not comply with the above Regulation by having R1's pepto bismol accessible when her Physician's Report revelaled she can not administer own prescription and PRN medications. This poses immediate health risk to person in care.
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Type B
08/21/2020
Section Cited

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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-Based on observation, the licensee did not comply with the above Regulation. LPA observed the carpet flooring in one of the residents' apartments stained which poses potential health and personal rights risks to person in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3